Columbia Commentary:
Do You Need Antibiotics Before Your Dental Appointments?

By Joel M. Laudenbach, D.M.D.
Columbia University College of Dental Medicine

Reviewed by the Faculty of Columbia University College of Dental Medicine

In April 2007, the American Heart Association (AHA) announced a new set of guidelines for dental patients with certain types of heart disease. The purpose of the guidelines is to help prevent infective endocarditis (IE). This disease used to be called bacterial endocarditis. It is an infection of the heart's lining or valves. It is uncommon. But when it occurs, it is serious. It can be life threatening.

Most people survive, but can develop serious health problems. These may include heart failure, blood clots or kidney problems. About 29,000 people develop IE each year in the United States.

This infection often begins in part of the heart that is damaged, diseased or repaired by surgery. Bacteria in the mouth may reach the heart by traveling through the bloodstream. Bacteria can enter the blood even through some everyday activities, the guidelines note. These include:

Chewing food

Brushing teeth

Flossing

Using a toothpick

Using a water irrigation device

Having dental disease makes it easier for bacteria to enter the bloodstream through these activities. Therefore, taking better care of your teeth and gums is the best way to reduce the bacteria in the bloodstream.

Dental procedures also can create an opening for bacteria to enter the bloodstream. This is why the AHA and the American Dental Association advise certain groups of people to take antibiotics before dental procedures. These groups have the highest risk for serious health problems or death if they develop IE.

The 2007 guidelines explain that pre-treatment with antibiotics is reasonable for people with these conditions:

Previous infective endocarditis (heart infection)

Artificial heart valve or valve repair using artificial material

Certain types of congenital heart disease (CHD). These types of disease are present at birth. They include:

Cyanotic heart disease that has not been repaired or was repaired incompletely. This includes people with shunts and conduits.

A heart defect that was completely repaired with a prosthetic material or device. In this case, antibiotics are advised only for the first six months after the procedure.

Any repaired heart defect that still has some defect at or next to the site of a prosthetic patch or device

Valve disease that develops after a heart transplant

People in these groups should take antibiotics before certain kinds of dental appointments. These include any procedures that involve cutting or manipulating the gums or the area around a tooth root.

Usually the antibiotic given is 2 grams of amoxicillin. It is taken 60 minutes before the dental procedure. Some people are allergic to amoxicillin and other drugs related to penicillin. These patients can use other antibiotics. For people who cannot swallow pills, the antibiotics come in liquid form.

Some kinds of dental procedures do not require pre-treatment. They include X-rays, fillings, injections into non-infected tissue, adjusting braces on teeth, and others.

The 2007 guidelines were written by a panel of experts. They updated a document from 1999. The older list recommended antibiotics before dental visits for more heart conditions than the new guidelines. The authors shortened the list for multiple reasons. The changes were based on newer research.

The 2007 guidelines also explain that taking antibiotics when not needed has risks as well. When antibiotics are taken too often, the bacteria can become resistant to the drugs. This makes them less effective. As a result, fewer antibiotics may be available to treat IE.

The guidelines also suggest that people get a dental exam before certain kinds of surgery. These include procedures to replace or repair a heart valve or congenital heart disease. In most cases, problems found in the dental exam could get treated before the heart surgery. This precaution could lead to fewer cases of IE.

Whether or not you have heart disease, your oral and medical health affect each other. Be sure to tell your dentist about your medical diseases, conditions and surgeries. Your dentist also needs to know what medicines you take. Your list should include over-the-counter vitamins and herbal supplements.

Discuss any planned medical surgeries with your dentist, as well as your physician. Ask if there may be any problem or potential interaction with dental procedures. Your dentist and physician may need to discuss your medical history to ensure your safety.

You can carry a card in your wallet that says you need to have antibiotics before dental procedures. It includes instructions on what medicines to take. You can print a copy of this card from the American Heart Association website.

Joel M. Laudenbach, D.M.D., is a lecturer in the Section of Oral Medicine and Orofacial Pain at the UCLA School of Dentistry. He maintains a private practice in oral medicine in the Los Angeles area. He is a former assistant professor and director of Geriatric Dentistry at Columbia University College of Dental Medicine.